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Year : 2019  |  Volume : 22  |  Issue : 7  |  Page : 957-960

Radiographic evaluation and determination of hypercementosis patterns in Al-Madinah Al-Munawwarah, Saudi Arabia: A retrospective cross-sectional study

1 Department of Oral and Maxillofacial Surgery, Taibah University Dental College and Hospital, Al-Madinah Al-Munawwrah, Saudi Arabia; Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Al-Azhar University (Girls Branch), Cairo, Egypt
2 Department of Oral Basic Science, College of Dentistry, Taibah University, Al-Madinah Al-Munawwarah, KSA
3 Department of Oral and Maxillofacial Surgery, Taibah University Dental College and Hospital, Al-Madinah Al-Munawwrah, Saudi Arabia
4 Department of Preventive Dental Sciences, Taibah University Dental College and Hospital, Al-Madinah Al-Munawwrah 42353, Saudi Arabia

Date of Acceptance28-Feb-2019
Date of Web Publication11-Jul-2019

Correspondence Address:
Dr. S A Elsayed
Department of Oral and Maxillofacial Surgery, Taibah University Dental College and Hospital, Al-Madinah Al-Munawwrah 42353

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_614_18

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Objectives: Hypercementosis (HC) is an asymptomatic excessive cementum deposition at the dental root apex. There is a lack of research that determines the pattern and associated factors of HC in Saudi Arabia. Materıals and Methods: A retrospective cross-sectional study was conducted on a random sample of 815 Orthopantomograms (OPGs) that was obtained from a total of 14003 female patients archived OPGs. The OPGs were retrieved from the Kodak Carestream-R4 database for the period between 2015 and 2017 at Taibah University Dental College and Hospital (TUDCH), Al-Madinah Al-Munawwarah, Saudi Arabia. Width and radiodensity of HC were measured and the distribution was calculated. Association between HC and factors including age and nationality were explored. Descriptive and inferential analyses were performed. Results: The mean/SD age of HC affected patients (9.8%) was 30.16 ± 13.1 years, of whom 55% were Saudis. The mean/SD width and radiodensity of the hypercementosed roots were 4.14 ± 1.2 mm and 119.86 ± 29.83, respectively. The mandibular teeth were more frequently associated with hypercementosis (65%) specifically first molars (47.5%), while the majority (64%) had a single unilateral distribution pattern. There was a non-significant association between nationality, age, and HC (P = 0.921, P = 0.633, respectively). Conclusion: Hypercementosis observed in 9.8% of female patients attending TUDCH which was primarily unilateral and prominently confined to the mandibular teeth roots. The complication of teeth extraction among female patients in Almadinah region should be anticipated.

Keywords: Female, hypercementosis, molars, pattern

How to cite this article:
Elsayed S A, Ayed Y, Alolayan A B, Farghal L M, Kassim S. Radiographic evaluation and determination of hypercementosis patterns in Al-Madinah Al-Munawwarah, Saudi Arabia: A retrospective cross-sectional study. Niger J Clin Pract 2019;22:957-60

How to cite this URL:
Elsayed S A, Ayed Y, Alolayan A B, Farghal L M, Kassim S. Radiographic evaluation and determination of hypercementosis patterns in Al-Madinah Al-Munawwarah, Saudi Arabia: A retrospective cross-sectional study. Niger J Clin Pract [serial online] 2019 [cited 2022 Jun 29];22:957-60. Available from:

   Introduction Top

Hypercementosis (HC) is an excess in cementum deposition around the root. There is a lack of information in the literature regarding HC and its surgical management.[1],[2],[3] This increase in the amount of cementum causes a change in the root apex dimension, which becomes rounded in shape macroscopically and radiographically. There are different forms of HC: Diffuse or focal, which can be moderate or marked and it might be localized or generalized.[4]

Hypercementosis is often asymptomatic and it has no clinical signs. The etiology of HC could be idiopathic or due to local or systemic conditions. It may be associated with functional stress due to occlusion forces, body reaction in response to periapical inflammatory disease, or systemic conditions such as atherosclerosis, acromegaly, arthritis, thyroid diseases, and Paget's disease.[1],[5],[6]

Hypercementosis incidence by ethnicity groups has been rarely investigated. Grzesik and Naravanan,[7] studied HC in 137 persons. The results revealed an average of 3.8 teeth with HC per person. The mean age was 47 years and the teeth most affected were the premolars.

In the present study, we had noticed an increased number of cases suffering from hypercementosis in our clinics, which make extraction more difficult and surgical exodontia frequently required. According to our review of the literature,[8],[9] there is a paucity of research on HC in Saudi Arabia, specifically in Al Madinah Al-Munawwarah region. Exploring HC in this region of Saudi Arabia will contribute to the current literature whilst shedding light on aspects of HC that include the shape, size, site, and pattern of distribution.

The purpose of the current study was to retrospectively evaluate HC, identify location, specific radiographic characteristics, and distribution among female patients who attended Taibah University Dentistry College and Hospital, Al-Madinah Al-Munawwarah, Saudi Arabia (SA).

   Materials and Methods Top

Study design, setting and sample calculation

The current study was a retrospective analytical cross-sectional study that was conducted in Taibah University Dental College and Hospital (TUDCH), Saudi Arabia. A convenience sample of 815 OPGs selected randomly, using random number in SPSS version 16, from the archived digital Orthopantomograms (OPGs) R4 Clinical and Practice Management Software database (CS Health, Inc. Rochester, NY, USA), for the period between January 2015 and November 2017.

The sample size was determined using single population proportion formula.[10] The estimate (5%) of HC in previous study [11] in SA was adopted with a 99% confidence interval (CI), 2% of marginal error using the total archived Digital OPGs (14003) for the period between 2015 and 2017. The calculated sample was 815 including 25 OPGs that were oversampled to compensate for the OPGs which were not meeting the inclusion criteria of the study.

Inclusion and exclusion criteria

Eight hundred and fifteen OPG records were screened for the presence of hypercementosis. Hypercementosis was considered if there was a radiopaque excessive cementum deposition surrounding the dental root apex without any artifact. Included patients were adults in the age range from 16 to 55 years. The exclusion criteria included those OPGs with an obvious artifact or with abnormal findings related to any other radiopaque lesions or bone tumors.

Data collection and study variables measurements

Demographic data including patient age, and nationality were collected from the Carestream (CS) R4 database.[12] The study outcome variables included: Site, side, number, and distribution of the HC. Radiographic characteristics of the hypercementosis including width, and densitometric analysis were assessed using control panel measurement tool of the Carestream (CS) R4 software.

Data analysis

Descriptive statistics for HC continuous dimensions, like width were reported using mean and standard deviation (SD). Categorical variable (nationality) reported as frequency and percentages. This was followed by the Chi-square and Unpaired t-tests to explore the association of HC with nationality and age. A P value of ≤ 0.05 was considered significant. The SPSS software version 16.0 (SPSS Inc., Chicago, IL, USA) was used to run the aforementioned analysis.

   Results Top

Sample characteristics

The mean/SD age of the sample population was 29.4 ± 15.4, while the mean/SD age of the HC affected patients was 30.16 ± 13.1 years, of whom 444 (55%) were Saudi nationals.

Aspects of hypercementosis

Eighty OPGs (9.8%) were found to have teeth affected with HC with different shapes, sizes, and distribution. The study revealed that HC was most commonly associated with mandibular first molars (4.7%) of which the mesial roots are the most affected followed by the second molar (2.8%). The least affected teeth were the centrals and canines (0.1%). Most of the affected teeth were found to have a single unilateral distribution (6.3%), [Table 1]. The right side of the mandible was affected more than the other side with a percentage of 5.2% and 4.7%, respectively.
Table 1: Descriptive distribution of the HC by tooth location, dimension, site and side

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As for the dimensions of HC, the mean width of the lesions was 4.1 ± 1.2 mm, and the mean radiographic density revealed by digital densitometric analysis on the same software of the HC site was 119.86 ± 29.83. Regarding the jaws, mandibular teeth were found to be affected nearly twice as much than maxillary teeth with a percentage of (6.4%), [Figure 1]. There was non-significant correlation between nationality and age and presence of HC (P = 0.921, P = 0.633, respectively).
Figure 1: Digital OPG showing densitometric linear dimensional analysis of hypercementosis lesion related to the distal root of the lower second molar

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   Discussion Top

In the present study, HC affected 9.8% of the current female sample population and this percentage is higher than reported by Bosshardt, study which was conducted on 22,000 patients with mean age of 42 years, where HC was observed radiographically in 1.7% of his patients.[13] Recently, Patil SR, et al.,[11] found the prevalence of HC to be 4.82% in a study carried out in the Saudi population of Aljouf.

Although HC has no clinical signs and symptoms and requires no treatment, it appears to be due to endodontic or periodontal problems which cause this reactional HC of the root; but this cannot explain cases with generalized HC where all teeth in both upper and lower jaw are affected.[3],[14],[15]

Alan S. Leider et al.,[16] described HC radiographically as that area of excessive cementum deposition which is attached to the root and surrounded by normal periodontal membrane and lamina dura. By these criteria; the authors differentiated HC from other root related radiopacities like, Periapical cemental dysplasia, condensing osteitis, and focal Periapical osteopetrosis, which lie outside the periodontal membrane and lamina dura. In our study, hypercementosed teeth were identified according to these criteria.

Objective definitive identification criteria of HC was first done in France using material of two medieval samples of which, 5756 teeth underwent macroscopic examination. The definition proposed to provide a better definition and assessment of HC, based on various statistically validated inclusion and exclusion criteria to distinguish moderate and marked forms of diffuse HC. These criteria verified that different forms of HC were associated with aging or certain local conditions.[17]

Additionally, previous studies reported HC in 84% of 104 skeletons from Barbados during the 17th to 19th centuries.[18] HC was also found in 10 out of 54 specimens collected from prehistoric coastal populations of Texas, USA.[4] A recent study [19] determined the prevalence of HC in North of Saudi Arabia as 4.82% with respect to patients and 0.96% with respect to teeth. No significant propensity for gender, jaw, and arch side was noted.

Based on objective and radiographic appearance, Pinheiro BC, et al.,[4] classified HC into three types: Diffuse HC, when the root assumes a club shape and this is the most frequent type according to his study which coincides with our study findings. The other two types are the focal HC, and the hypercementosis in the shape of a shirt sleeve cuff, however, these types were never seen in our study.[20]

In Germany, a study aimed at determining the occurrence of HC was conducted.[21] The findings revealed that mandibular teeth were approximately twice as often associated with HC than maxillary teeth,[22] which is similar to our study findings, as well as the observation that HC was significantly more often related to posterior teeth than the anterior. In the present study, molars were more commonly affected followed by premolars with only 0.1% occurrence in incisors. However, we disagreed with their observation that there was no significant difference regarding the side of the affected roots.

Our study results revealed that the right side is more frequently affected (5.2%) than the left side. Moreover, the findings of this study are in accordance with Bürklein et al.,[21] who showed that the mandibular teeth were affected more than the maxillary teeth.

The strength of the present study appears to be the paucity of data regarding hypercementosis prevalence among the Saudi population in the literature. The evaluation of HC was carried out by three examiners; therefore, it was possible to rule out inter- and intraobserver variations. OPG is the standardized radiograph used in our faculty for initial screening and data archiving of all patients and therefore it allows us to examine a large sample.[12] Additionally, a reliability test was conducted before collecting the data, therefore, trusted measurements were obtained.

Furthermore, we try to represent for the first time a detailed description of the radiographic characteristics of this rare condition including position, size, and radiodensity of the HC, which we didn't find in the literature. The limitations of the study should be acknowledged, first, we used the OPGs which is considered a two-dimensional view analysis with respect to computed tomogram (CBCT), which is not routinely used due to cost. Secondly, the results were only reported for female patients due to the cultural context of the study region.

   Conclusion Top

A significant number of female patients attending TUDCH had hypercementosis which was primarily confined to the mandibular teeth. Surgeons, general practitioners, and orthodontists should be aware of this condition.

Ethical considerations

This study was reviewed and approved by the Research Ethical Committee at Taibah University for clearance (TUCDREC2Ol7O3O7Farghal). We worked on anonymized data and did not link this data to identify the participants. Data were collected retrospectively from patients' archived radiographs without any active interventions. This study was conducted according to the principles of the World Medical Declaration of Helsinki.


Authors would like to express their appreciation to Dr. Tamer Hifnawy, Professor of Public Health and Community Medicine in the College of Dentistry at Taibah University, for his skilled guidance and support in the research course and many thanks to Engineer. Bilal Khaled Alshantoot and Bashaer Abdul Kareem Alhejaily at Taibah University Dental College for their great help in data adjustment.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Dargue A. 'Acquired' concrescence causing surgical complications-A report of two cases. Oral Surg 2017;10:e92-7.  Back to cited text no. 1
Jeyaraj CP. Clinicopathological study of a case of cementoblastoma and an update on review of literature. J Oral Maxillofac Surg Med Pathol 2014;26:415-20.  Back to cited text no. 2
Oliver R. Prevention and management of oral surgery complications in general dental practice. Br Dent J 2014;216:263-4.  Back to cited text no. 3
Pinheiro BC, Pinheiro TN, Capelozza AL, Consolaro A. A scanning electron microscopic study of hypercementosis. J Appl Oral Sci Rev 2008;16:380-4.  Back to cited text no. 4
Fragiskos FD. Oral Surgery. vol. 7th ed, Springer-Verlag Berlin Heidelberg, NewYork: Springer; 2007. p. 155-64.  Back to cited text no. 5
Hatori M, Ito I, Tachikawa T, Nagumo M. Familial florid cemento-osseous dysplasia. Asian J Oral Maxillofac Surg 2003;15:135-7.  Back to cited text no. 6
Grzesik WJ, Narayanan AS. Cementum and periodontal wound healing and regeneration. Crit Rev Oral Biol Med 2002;13:474-84.  Back to cited text no. 7
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Brasher WJ, Brannon RB. Sequestration of root cementum in an endodontic- periodontally involved tooth: Report of an unusual case. J Endod 1982;8:413-6.  Back to cited text no. 9
Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for prevalence studies. Arch Orofac Sci 2006;1:9-14.  Back to cited text no. 10
Patil SR, Araki K, Yadav N, Ghani HA. Prevalence of hypercementosis in a Saudi Arabian population: A cone beam computed tomography study. J Oral Res 2018;7:94-7.  Back to cited text no. 11
Elsayed SA, Alolayan AB, Alahmadi A, Kassim S. Revisited maxillary sinus pneumatization narrative of observation in Al-Madinah Al-Munawwarah, Saudi Arabia: A retrospective cross-sectional study. Saudi Dent J 2018; Available from: [Last accessed on 2018 Nov 10]. Doi:  Back to cited text no. 12
Bosshardt DD, Selvig KA. Dental cementum: The dynamic tissue covering of the root. Periodontol 2000 1997;13:41-75.  Back to cited text no. 13
Costa BC, de Oliveira GJ, Chaves Md, da Costa RR, Gabrielli MF, Guerreiro-Tanomaru JM, et al. Surgical treatment of cementoblastoma associated with apicoectomy and endodontic therapy: Case report. World J Clin Cases 2016;4:290.  Back to cited text no. 14
Štamfelj I, Vidmar G, Cvetko E, Gašperšič D. Cementum thickness in multirooted human molars: A histometric study by light microscopy. Ann Anat 2008;190:129-39.  Back to cited text no. 15
Leider AS, Garbarino VE. Generalized hypercementosis. Oral Surg Oral Med Oral Pathol 1987;63:375-80.  Back to cited text no. 16
D'Incau E, Couture C, Crépeau N, Chenal F, Beauval C, Vanderstraete V, et al. Determination and validation of criteria to define hypercementosis in two medieval samples from France (Sains-en-Gohelle, AD 7th-17th century; Jau-Dignac-et-Loirac, AD 7th-8th century). Arch Oral Biol 2015;60:293-303.  Back to cited text no. 17
Corruccini RS, Jacobi KP, Handler JS, Aufderheide AC. Implications of tooth root hypercementosis in a Barbados slave skeletal collection. Am J Phys Anthropol 1987;74:179-84.  Back to cited text no. 18
Patil SR, Yadav N. Case report generalized hypercementosis with multiple missing teeth in a young female: A rare case report. Int J Heal Allied Sci 2015;178-80.  Back to cited text no. 19
Consolaro A, Consolaro RB, Francischone LA. Cementum, apical morphology and hypercementosis: A probable adaptive response of the periodontal support tissues and potential orthodontic implications. Dent Press J Orthod 2012;2117:21-30.  Back to cited text no. 20
Bürklein S, Jansen S, Schäfer E. Occurrence of hypercementosis in a German population. J Endod 2012;38:1610-2.  Back to cited text no. 21
Rechenberg DK, Thurnheer T, Zehnder M, Macedo RG, Nikitenko SI, Verhaagen B, et al. Wladimir Adlivankine European society of endodontology research prize. Int Endod J 2011;44:1176-221.  Back to cited text no. 22


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